Filter fields displayed by checking a Data Group. To select a field, click your mouse on the box at the beginning of each row.
Clicking Submit will send your request to the Biostatistics department. For questions about how to use this tool, contact Suzanne Hunt, shunt@kumc.edu

14. Subjects years of education (report achieved level using the codes below- if an attempted level is not completed, enter the number of years attended). High school/GED = 12, Bachelors degree = 16, Masters degree = 18, Doctorate = 20 years (99=Unknown)

1 Lives alone,2 Lives with one other person: a spouse or partner,3 Lives with one other person: a relative, friend, or roommate,4 Lives with caregiver who is not spouse/partner, realtive, or friend,5 Lives with a group (related or not related) in a private residence,6 Lives in group home (e.g., assisted living, nursing home, convent),9 Unknown

14. Subjects years of education (report achieved level using the codes below- if an attempted level is not completed, enter the number of years attended). High school/GED = 12, Bachelors degree = 16, Masters degree = 18, Doctorate = 20 years (99=Unknown)

7. Informants years of education(report achieved level using the codes below- if an attempted level is not completed, enter the number of years attended). High school/GED = 12, Bachelors degree = 16, Masters degree = 18, Doctorate = 20 years (99=Unknown)

0 None Fully oriented,0.50.5 Questionable Fully oriented except for slight difficulty with time relationships.,1 Mild Moderate difficulty with time relationships; oriented for place at examination; may have geographic disorientation elsewhere.,2 Moderate Severe difficulty with time relationships; usually disoriented to time, often to place.,3 Severe Oriented to person only.

0 None Independent function at usual level in job, shopping, volunteer and social groups.,0.50.5 Questionable Slight impairment in these activities.,1 Mild Unable to function independently at these activities, although may still be engaged in some; appears normal to casual inspection.,2 Moderate No pretense of independent function outside the home; appears well enough to be taken to functions outside the family home.,3 Severe No pretense of independent function outside the home; appears too ill

2. Does the subject have normal cognition (global CDR=0 and/or neuropsychological testing within normal range) and normal behavior (i.e., the subject does not exhibit behavior sufficient to diagnose MCI or dementia due to FTLD or LBD)?

3a. Does the clinician believe there has been a current meaningful decline in the subjects memory, non-memory cognitive abilities, behavior, or ability to manage his/her affairs, or have there been motor/movement changes? (if no, end form here)

d. Disinhibition (Does the subject use inappropriate coarse language or exhibit inappropriate speech or behaviors in public or in the home? Does s/he talk personally to strangers or have disregard for personal hygiene?)

d. Slowness (Has the subject noticeably slowed down in walking or moving or handwriting, other than due to an injury or illness? Has his/her facial expression changed, or become morewooden or masked and unexpressive?)

f. Fluctuating cognition (Does s/he have pronounced variation in attention and alertness, noticeably over hours or days? For example, long periods of staring into space or lapses, or times when his/her ideas have a disorganized flow.)

10. Arising from chair (patient attempts to rise from a straight-backed chair, with arms folded across chest)

0 Normal.,1 Slow or may need more than one attempt.,2 Pushes self up from arms of seat.,3 Tends to fall back and may have to try more than one time, but can get up without help.,4 Unable to arise without help.,8 Untestable (specify reason):

0 None.,1 Minimal slowness, giving movements a deliberate character could be normal for some persons possibly reduced amplitude.,2 Mild degree of slowness and poverty of movement which is definitely abnormal. Alternatively, some reduced amplitude.,3 Moderate slowness, poverty or small amplitude of movement.,4 Marked slowness, poverty or small amplitude of movement.,8 Untestable (specify reason):

0 Normal.,1 Walks slowly may shuffle with short steps, but no festination (hastening steps) or propulsion.,2 Walks with difficulty, but requires little or no assistance may have some festination, short steps, or propulsion.,3 Severe disturbance of gait requiring assistance.,4 Cannot walk at all, even with assistance.,8 Untestable (specify reason):

0 Absent.,1 Slight or detectable only when activated by mirror or other movements.,2 Mild to moderate.,3 Marked, but full range of motion easily achieved.,4 Severe range of motion achieved with difficulty.,8 Untestable (specify reason):

0 Absent.,1 Slight or detectable only when activated by mirror or other movements.,2 Mild to moderate.,3 Marked, but full range of motion easily achieved.,4 Severe range of motion achieved with difficulty.,8 Untestable (specify reason):

0 Absent.,1 Slight or detectable only when activated by mirror or other movements.,2 Mild to moderate.,3 Marked, but full range of motion easily achieved.,4 Severe range of motion achieved with difficulty.,8 Untestable (specify reason):

0 Absent.,1 Slight or detectable only when activated by mirror or other movements.,2 Mild to moderate.,3 Marked, but full range of motion easily achieved.,4 Severe range of motion achieved with difficulty.,8 Untestable (specify reason):

0 Absent.,1 Slight or detectable only when activated by mirror or other movements.,2 Mild to moderate.,3 Marked, but full range of motion easily achieved.,4 Severe range of motion achieved with difficulty.,8 Untestable (specify reason):

0 Absent.,1 Slight present with action.,2 Moderate in amplitude, present with action.,3 Moderate in amplitude with posture holding as well as action.,4 Marked in amplitude interferes with feeding.,8 Untestable (specify reason):

0 Absent.,1 Slight present with action.,2 Moderate in amplitude, present with action.,3 Moderate in amplitude with posture holding as well as action.,4 Marked in amplitude interferes with feeding.,8 Untestable (specify reason):

0 Absent.,1 Slight and infrequently present.,2 Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present.,3 Moderate in amplitude and present most of the time.,4 Marked in amplitude and present most of the time.,8 Untestable (specify reason):

0 Absent.,1 Slight and infrequently present.,2 Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present.,3 Moderate in amplitude and present most of the time.,4 Marked in amplitude and present most of the time.,8 Untestable (specify reason):

0 Absent.,1 Slight and infrequently present.,2 Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present.,3 Moderate in amplitude and present most of the time.,4 Marked in amplitude and present most of the time.,8 Untestable (specify reason):

0 Absent.,1 Slight and infrequently present.,2 Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present.,3 Moderate in amplitude and present most of the time.,4 Marked in amplitude and present most of the time.,8 Untestable (specify reason):

0 Absent.,1 Slight and infrequently present.,2 Mild in amplitude and persistent, or moderate in amplitude, but only intermittently present.,3 Moderate in amplitude and present most of the time.,4 Marked in amplitude and present most of the time.,8 Untestable (specify reason):

6. ANXIETY 6a. Does the patient become upset when separated from you? Does he or she have any other signs of nervousness, such as shortness of breath, sighing, being unable to relax, or feeling excessively tense?

9. DISINHIBITION 9a. Does the patient seem to act impulsively? For example, does the patient talk to strangers as if he or she knows them, or does the patient say things that may hurt peoples feelings?